Be Bold. Be Beautiful. Be You! Consent Form Full Name *Email Address *Phone Number *Date of Birthday *OccupationStreet Address *City *State *Zip Code *Where did you hear about us? *FriendInstagramFacebookGoogle SearchYelpPlease Read Carefully and Answer Each SectionHave you received chemotherapy or radiation in the past year? *YesNoList any medications you have been taking in the past 6 months: *Check any of the following allergies that apply: *LanolinLatexGlycerinNovocaine/Lidocaine/ Tetracaine, Epinephrine, DermacainePaintMetalsCrayonsFoodsDyesHairOther/allergiesNoneCheck any of the following health conditions that apply to you: *AnemiaLow Blood PressureHigh Blood PressureArtificial Heart ValvesDiabetesHemophilia (blood clot disorder, prolong bleeding, etc.)Circulatory ProblemsEpilepsyTumors, Growth, or CystsThyroid DisturbancesHepatitis (A, B, C, D types)CancerHistory HIVHistory of: Methicillin-Resistant Staphylococcus Aureus (MRSA), Vancomycin-Resistant Enterococcus (VRE), Multi-Drug-Resistant Mycobacterium Tuberculosis (MDR-TB), or Carbapenem-Resistant Enterobacteriaceae (CRE) Gut BacteriaAutoimmune disorderPregnant/NursingTaking blood thinners, such as: Aspirin, Ibuprofen, Alcohol, or CoumadinAny diseases or disorders not listedSkin TypesUse of skin care products containing Retin-A, Glycolic Acid, or Alpha Hydroxyl within last 4 weeksUse of any product for acne treatment within last 4 weeksChemical Peel or Laser within the last 4 weeksAlopecia (hair loss)Botox, Fat, Collagen or Filler InjectionsForehead/Brow Lift/Facelift surgeryBrow Lash TintingMakeup SensitivitiesHealing ProblemsKeloid ScarsBruise EasilyFainting Spells or DizzinessDetails for Previous QuestionAcknowledgmentThis form is designed to give the information needed to decide whether to undergo any semi-permanent makeup application. If you have any questions, please don’t hesitate to ask. Although the permanent makeup procedure is effective in most cases, I can’t guarantee any specific result from the procedure. This is the process of inserting pigment into the basal layer of the epidermis. It is a form of tattooing, though semi-permanent; it is considered a permanent marking. All instruments that enter the skin or come in contact with body fluids are disposable and disposed of after use. Cross-contamination guidelines are strictly adhered to. Healing is different for each client. The pigment will fade anywhere from 40%-50% after the initial session. This is a 2-part process, and the procedure is not complete without a touch-up. A touch-up session is highly advised 6-8 weeks after the initial session, during which we will fine-tune any areas that need correction. The pigment will fade over time. You would need a color boost every 2-2.5 years to maintain a fresh, natural look. Consent *I agree that all the above information is true and accurate to the best of my knowledge.Full Name *Consent Date *Photography Release ConsentWe would like your permission to use these photos for advertising. For example: Portfolios, online and print ads, etc. Your consent is necessary regarding this. Please circle and indicate with your signature if you would like your photos used or not used in advertising. *Yes, feel free to use themNo, please do not use themFull NameEmail AddressPhoneConsent DateSpecial requests, concerns, or remarks for the Artist:Possible Risks, Hazards, and Complications Pain: There can be pain even after the topical anesthetic has been used. Anesthetics work better on some people than on others. Infection: Infection is possible but very unusual. The treated areas must be kept dry and clean. Please see the “After Care” sheet for detailed instructions. Uneven Pigmentation: This can result from poor healing, infection, bleeding, or many other causes. Your follow-up appointment will likely correct any uneven appearance. Asymmetry: Every effort will be made to avoid asymmetry, but our faces are not symmetrical, so adjustments may be needed during the follow-up session to correct any unevenness. Swelling or Bruising: Some people bruise or swell more than others. Ice packs may help reduce the swelling. The swelling or bruising typically disappears in 1-5 days. Some people don’t bruise or swell at all. Anesthetics: Topical anesthetics are used to numb the area to be tattooed. Lidocaine Prilocaine, Benzocaine, Tetracaine, and/or Epinephrine cream and/or liquid are used. If you are allergic to any of these, please inform me now. Allergic Reaction: Although an allergy is unusual, there is always a possibility of an unknown allergy to the pigments and materials used during the procedure. The alternative to these possibilities is to use traditional cosmetics and NOT undergo the Semi-Permanent Eyebrow procedure.Consent and release for procedures performed:Full NameConsent DateStatement of ConsentPlease read and check all lines:I am over the age of 18, am not under the influence of drugs or alcohol, am not pregnant or nursing, and desire to receive the indicated semi-permanent pigmentation procedure. The general nature of cosmetic micro-pigmentation, as well as the specific procedure to be performed, has been explained to me clearly.Aftercare instructions have been explained to me, and a written copy has been given to me to retain in my possession, which I will follow to the best of my ability. If I have questions, I will call or email you.I understand that a certain amount of discomfort is associated with this procedure and that swelling, redness, and bruising may occur.I have been advised that the procedure result can be affected by the following: medication, skin characteristics (dry, oily, sun damaged, thick or thin skin types), personal PH balance of the skin, alcohol intake, and smoking, post procedure aftercare.I understand that the treatment I have chosen is for cosmetic purposes only, and no guarantees have been made to me concerning the results of the procedure.I understand that Retin A, Renova, Alpha Hydroxy, and Glycolic Acids must not be used on treated areas. They will alter the color and cause premature exfoliation of the pigment.I understand that tanning beds, pools, some skincare products, and medications can affect my permanent makeup.I understand that successful color saturation can NOT be guaranteed due to hidden scar tissue.I understand that implanted pigment color can slightly change or fade over time due to circumstances beyond your control. I will need to maintain the color with future applications and a touch-up session within 8-12 weeks.I acknowledge that the proposed procedures(s) involve risks inherent in the procedure and have possibilities of complications during and/or following the procedures, such as: infection, misplaced pigment, poor color retention, hyper-pigmentation, scarring, bleeding.I have been advised that a touch-up session is highly recommended to make any adjustments to shape, color, and to fill any pigment that may have had poor retention. Touch-ups must be completed within8-12 weeks of the initial procedure.I agree to follow all pre-procedure and post-procedure instructions as provided and explained to me by the technician. Failure to do so may jeopardize my chance for a successful procedure.I have been quoted the cost of today’s appointment.I certify that I have read or have read to me the contents of this form. I understand the risks and alternatives involved in this procedure(s). I have had the opportunity to ask questions, and all of my questions have been answered. I acknowledge that I have reviewed and approved the material given to me.I authorize the technician(s) listed below to perform today's permanent makeup procedure for my eyebrows.Technician NameTechnician NameConsent DateAftercare InstructionsYou must follow these instructions after your procedure: Day One (Day of treatment): please make sure to blot your brows every 2-3 hours with a clean cotton pad, dampened with drinking water ( no tap water) to remove any lymph fluid and avoid build-up. NOTE: Wash your hands with a disinfectant soap before touching your eyebrows and/or applying the post-care cream. Day Two – Ten: Repeat the wiping of the brows at least 2 times a day. At night, wash the treated area with warm water and mild soap like Cetaphil. The following must be avoided during the first 10 days post-procedure: Applying makeup, strong cleanser, facial exfoliating products, toner, Etc. on the brows for 10 days Practicing sports and working out as sweating can cause the pigment to fade prematurely. Swimming, steam/dry sauna, hot bath, or Jacuzzi Sun tanning or salon tanning. Absolutely No Sun, sweating, or tanning before the procedure or after the procedure for 2 weeks. Do not have a tan/sunburn on your face before your procedure. The tan will exfoliate and take color with it as it fades. Any laser or chemical treatments or peelings and/or any creams containing Retin-A or Glycolic Acid on the face or neck Picking, peeling, or scratching of the pigmented area to avoid scarring of the area or removal of the pigment Touching of the eyebrow area except for when rinsing and applying the post-care cream with a cotton swab Itching and flaking may appear during the first seven days post-procedure. However, experience has shown that by following these after-care instructions, these symptoms may quickly disappear. Gently tap on the brows to relieve the itch. Submit